General Survey

Assessment Normal Findings Actual Findings Interpretation and

analysis
1. Observation of body Body built Body built Normal
built, height and proportionate to height proportionate to height
weight in relation to and weight, client’s and weight, client’s
client’s age, lifestyle age, lifestyle and age, lifestyle and
and health. health. health.

2. Observation of Relaxed and erect Client is unable to Deviation from

client’s posture and posture; coordinated ambulate normal
gait, standing, sitting movements.
and walking.

3. Observation of the No body odor or No body odor or

client’s overall minor body odor minor body odor Normal
hygiene and grooming relative to work or relative to work or
in relation to person’s exercise. exercise.
activities prior to
assessment.

4. Note body and No breath odor No breath odor Normal

breath odor in relation
to activity level.

5. Observation for No distress noted No distress noted Normal

signs of distress in
posture or facial
expression.

6. Note obvious signs Healthy Appearance Pale and weak Deviation from
of health and illness. normal
Pallor and weakness
may be due to
impaired gas
exchange and
decreased oxygen
concentration in the
body.

7. Assessment of Cooperative, able to Cooperative, able to Normal

client’s attitude. follow instructions follow instructions

8. Note client’s Appropriate to Client is in good affect Normal

affect/mood; situation and mood; client’s
assessment of the responses are
appropriateness of the appropriate to the
client’s responses. situation.

9. Listen for quantity Understandable, Understandable, Normal

of speech (amount and moderate pace, clear moderate pace, clear
pace), quality tone and inflection, tone and inflection,
(loudness, clarity, exhibits thought exhibits thought
inflection), and association. association.
organization
(coherence of thought,
overgeneralization and
vagueness).

10. Listen for Logical sequence, Logical sequence, Normal

relevance and makes sense, has sense makes sense, has sense
organization of of reality. of reality.
thoughts.